Endoscopy is defined as a direct visualization of body cavities by the use of an instrument called ENDOSCOPE (a telescope with a built-in light for illumination). When the body cavity of the abdomen is entered during the operation, it is called LAPAROSCOPY, on the chest cavity it's THORACOSCOPY and the lower abdomen or pelvic region it's called PELVISCOPY.
The early beginning of ENDOSCOPIC SURGERY took place in Europe and pioneered by Gynecologists where they performed tubal ligations, removal of ovarian tumors or cysts, lysis of adhesions and as a diagnostic procedure. Some of these surgeons were brave enough to remove the appendixes through 1/2 inch abdominal incisions.
It was the successful and safe removal of the appendix that led the aggressive and innovative general surgeons to explore tile vast potential of the new surgical technology. Thus, the removal of the gall bladder or Laparoscopic Cholecystectomy was first performed in 1987 and only attracted minor curiosity. General surgeons were slow in accepting this new video assisted surgery but the procedure crossed the Atlantic in the early 1988 and thereafter several U.S. Surgical Centers began using this new operative technology with unerring success. The Laparoscopic Cholecystectomy has now become a standard operative procedure in removing a disease gall bladder.
In the first few years of Laparoscopic surgery, surgeons have encountered procedural difficulties. One difficulty is securing bleeding blood vessels, ducts and soft tissues. Several instruments and innovations to secure blood vessels were developed through the years and some are new like stapling divices, Laser coagulation and Electrocoagulation. There are also knot pushers with distinct individual features capable at securing bleeders but have significant drawbacks in some instances.
Devices like vessel clips and staples can stop bleeding points from small size vessels but sometimes not effective when dealing with larger caliber vessels. A vessel clip can not be used on bleeding flat surface. Likewise, the Laser and Electro-coagulation are limited on their efficacy to small vessels or ducts. Collateral burns to adjacent tissues or organs remote from the bleeding site may become a serious complication.
There are several Laparoscopic ligators or knot pushers presently being used have individual drawbacks in securing bleeding site or potential bleeder. One such knot pusher is made of plastic shaft with a central channel where suture is threaded into the entire length of the shaft and in the forward end has a preformed knotted loop, the latter anchored and looped around the bleeding vessel or potential bleeder and the knot is pushed and tightened against the surgical site. A slip knot is always formed by this device or any other tools using the preformed knotted loop and could not be used in larger caliber vessels or ducts and bleeding flat surface where there is no `pedicle` to anchor the loop.
Devices or tools that uses preformed knotted loop has another drawback in that when the knot is run down to the surgical site there is a `sawing` action of the ligature on the tissue or vessels causing tear, a serious complication. An added drawback on devices with preformed knotted loop is that the free end of the suture must be threaded through a hole at the guide end of the tool after each throw has been delivered to the surgical site and this can be time consuming and also requires an assistant to perform the task.
Another type of knot pusher have a pair of spaced arms forming a circular opening for guiding the suture permits easy slipping of throws fashioned extracorporeally to the surgical site but a skew tension must be applied on either knot tether. The lateral tension necessary to tighten the knot posses the danger of inadvertent injury to adjacent organs. These devices can only produce slip knots so that the surgeon must deliver more than three throws in succession to comfortably secure the bleeder or tissue.
Some of the knot pushers currently used in Laparoscopic surgery are selective on the suture material that each tool can readily slide the throws smoothly to the surgical site. There are devices that have difficulty in sliding two intertwine of monofilament sutures and when pressure is applied on the throw, it gets stuck to the guide end.
It is imperative to create square knots from two or three run down throws tightened on top of each other against the vessel being shut off or two opposing tissues being approximated or sutured. The square knot (non-slip) is unyielding to the internal pressure of a vessel undoubtedly more desirable surgical knot in securing tissues. To develop a square knot, the surgeon must maintain tension on the suture ends while creating throws and sliding them with the pusher to the surgical site. If the tension is not maintained appropriately, loosening of the knot takes place a situation which would be detrimental in securing of the tissue involved. Surgeons using the standard maneuver of sequential throw--run down--throw will not be able to maintain the necessary tension and as a result a loose knot is formed.